Effect of Pay for Performance on the Management and Outcomes of Hypertension in the United Kingdom

The Issue

The impact of pay-for-performance programs on the quality of care for chronic conditions, and the outcomes of that care, is largely unknown, though such programs are increasingly common. Commonwealth Fund–supported researchers examined how a large-scale pay-for-performance program in the United Kingdom affected management and outcomes for one such condition—hypertension.
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What the Study Found

Based on review of data for 470,725 patients with hypertension, researchers found that there were no changes in blood-pressure monitoring, control, or treatment intensity 36 months after implementation of the payment incentives. In terms of outcomes, the incentives had no effect on the incidence of stroke, myocardial infarction, renal failure, heart failure, or all-cause mortality rates.

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Conclusions

The authors note that the quality of care for hypertension had been increasing in the U.K. prior to implementation of this program and suggest that the performance targets may have been insufficiently ambitious. They conclude that, based on the U.K. experience, "generous financial incentives…may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions."

Citation

B. Serumaga, D. Ross-Degnan, A. J. Avery et al., "Effect of Pay for Performance on the Management and Outcomes of Hypertension in the United Kingdom: Interrupted Time Series Study," BMJ, Jan. 25, 2011 342.

Effort To Reward Medicare Advantage Plans Draws Criticism - Kaiser Health News

By Julie Appleby

Lake Wobegon has come to Medicare – and a key advisory panel doesn't like it.

The panel, the Medicare Payment Advisory Commission (MedPac), in a Jan. 6 letter does not mention the fictional Lake Wobegon, where all the children are above average. But it hints that not every Medicare Advantage insurer deserves to be above average.

The letter, to Dr. Donald Berwick, who heads the agency overseeing Medicare, criticizes a move to extend quality bonus payments meant for top-performing health insurers to those with lower scores. In fact, the new bonus program will reward even those plans highlighted on Medicare's own website as being poor performers over three consecutive years, according to the letter signed by MedPac Chairman Glenn Hackbarth.

The effort by the Centers for Medicare and Medicaid Services (CMS) will likely result in "far greater program costs" than the reward system called for by Congress in the health law and reduces insurers' incentive to achieve high performance, the letter concludes.

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Healthcare Economist · Did pay-for-performance work in the UK?

A paper by Sutton, Elder Guthrie and Watt (2010) describes the UK’s National Health Service’s (NHS) adoption of the Quality and Outcomes Framework (QOF) in April 2004. In general, P4P programs can have positive or negative spillovers. An example of a positive spillover would be the adoption of EMR to comply with certain P4P initiatives, but which also improves productivity in other areas. A negative spillover would occur if physicians focus on getting the P4P bonuses, but decrease effort in unmeasured areas which could be more important to the patient’s health.
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AMNews: Aug. 31, 2009. Accountable care organizations: A new idea for managing Medicare ... American Medical News

By Jane Cys, AMNews correspondent
The accountable care organization is one of the latest designs for managing Medicare that is gaining traction among policymakers desperate to control costs and boost quality in the system. Proponents of the concept want to see it tested along with such alternatives as patient-centered medical homes, pay-for-performance and payment bundling.

A typical Medicare ACO would include a hospital, primary care physicians, specialists and potentially other medical professionals. Services would still be billed under fee-for-service, but the organization's members would coordinate care for their shared Medicare patients with the goal of meeting and improving on quality benchmarks. Because ACO members are held jointly accountable for this care, they would share in any cost savings that stem from the quality gains.

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Health Business Blog » Blog Archive » Broader implications of Aetna’s never event policy

David E. Williams of the Health business blog

In normal industries when someone makes a mistake it has negative financial consequences. When a factory damages a widget during the manufacturing process, the company can’t sell the final product and has to absorb the labor, material and capital costs of the wasted efforts. To survive in a competitive industry factories focus on increasing first-pass yield, reducing scrap, and pursuing initiatives such as six sigma to virtually eliminate defects. Factories with low yields and high defect rates go out of business. That’s capitalism and it works.

Health care is a lot different. If a hospital or physician makes an error, they can typically bill for the work involved in making that error. Not only that –they can also bill for the work involved in correcting the mistake or mitigating the damage! Unlike sub-par factories, hospitals with low yields and high defects can be just as profitable or more profitable than hospitals that perform much better. And thanks to the complexity of health care and lack of solid measurement and reporting, such performance may be obscured from the general public and even from hospital management itself.
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NEJM -- Effects of Pay for Performance on the Quality of Primary Care in England

Stephen M. Campbell, Ph.D., David Reeves, Ph.D., Evangelos Kontopantelis, Ph.D., Bonnie Sibbald, Ph.D., and Martin Roland, D.M Background A pay-for-performance scheme based on meeting targets for the quality of clinical care was introduced to family practice in England in 2004. Methods We conducted an interrupted time-series analysis of the quality of care in 42 representative family practices, with data collected at two time points before implementation of the scheme (1998 and 2003) and at two time points after implementation (2005 and 2007). At each time point, data on the care of patients with asthma, diabetes, or coronary heart disease were extracted from medical records; data on patients' perceptions of access to care, continuity of care, and interpersonal aspects of care were collected from questionnaires. The analysis included aspects of care that were and those that were not associated with incentives. Results Between 2003 and 2005, the rate of improvement in the quality of care increased for asthma and diabetes (P<0.001) but not for heart disease. By 2007, the rate of improvement had slowed for all three conditions (P<0.001), and the quality of those aspects of care that were not associated with an incentive had declined for patients with asthma or heart disease. As compared with the period before the pay-for-performance scheme was introduced, the improvement rate after 2005 was unchanged for asthma or diabetes and was reduced for heart disease (P=0.02). No significant changes were seen in patients' reports on access to care or on interpersonal aspects of care. The level of the continuity of care, which had been constant, showed a reduction immediately after the introduction of the pay-for-performance scheme (P<0.001) and then continued at that reduced level. Conclusions Against a background of increases in the quality of care before the pay-for-performance scheme was introduced, the scheme accelerated improvements in quality for two of three chronic conditions in the short term. However, once targets were reached, the improvement in the quality of care for patients with these conditions slowed, and the quality of care declined for two conditions that had not been linked to incentives. Continuity of care was reduced after the introduction of the scheme. Read More

The Time Has Come for Comprehensive Health Reform: Statement from The Commonwealth Fund Commission on a High Performance Health System

The Commonwealth Fund Commission on a High Performance Health System urges the President and Congress to move quickly to enact comprehensive reform. President-elect Obama and the 111th Congress will face many daunting challenges when they arrive in Washington in January, and the economic crisis will rightly demand priority attention. But with ever-spiraling health care cost increases and clear evidence that a growing number of Americans lack access to affordable, well-organized care, the crisis in our health system must also receive immediate attention. We cannot afford to continue on our present course.

AMA survey results: Medicare rated as poor performer during debut of pay-for-reporting

By David Glendinning, AMNews staff. Nov. 17, 2008

Physicians will decide whether to participate in 2009 without knowing if they will receive a bonus for 2008.


Even as Medicare's Physician Quality Reporting Initiative approaches the end of its 2008 run, many doctors are still trying to figure out what went wrong with the 2007 PQRI.


Confidential physician feedback reports from last year's initiative, which for the first time offered Medicare bonuses for successfully reporting quality measures, became available to participating practices starting in August. Since then, many participants have been struggling to make sense of the information that they received -- if they were able to access it at all.

Hospital can share P4P bonus with physicians, OIG says

By Amy Lynn Sorrel, AMNews staff. Nov. 10, 2008, American Medical News The opinion could allow more expanded collaborative efforts to improve quality and contain costs, experts said.